PHYSICAL EXAMINATION

General
1) Wash or sanitize hands before beginning examination.
2) Display a professional demeanor towards the patient during the exam
a) Introduce yourself as a medical student
b) Use the patient’s last name
c) Dress professionally in white coat
3) Appropriate interaction with the patient—sensitivity to privacy, comfort and dignity
4) Drape the patient appropriately during each segment of the exam
5) Thank the patient after doing the examination.

I. GENERAL SURVEY
Good afternoon po, Ma’am/ Sir. I am Krystel Batino, one of the assigned doctors in managing your case.
How did it start? (OPQRST)

PMH
FHx
S&E Hx
ROS
PE

Once again, good morning doctors! Thank you so much for waiting.

Never ignore a gut feeling, but never believe that it’s enough.

GD: Today I present to you the case of ….

CC: Patient is a known ___ and was in her usual state of health, until _____…
Or He/She came in due to a __day which dates back ____…
…3 days prior to admission, when she experienced ___ characterized as ____. This was followed by symptoms of ___. However there were no symptoms of ____.
Consultation was done at ____. Medications taken were ___ for which she was compliant to ____, offerring relief of _____.

There was persistence of symptoms of ___ up until few hours prior to admission, when the patient can no longer tolerate the ___, now described as ____. Hence, the
patient decided to seek consult at the ER of this institution.
(ask ROS that you could think of already/ write on the side)

Probing further past medical history revealed that …(SHAlI-I-Meat)

Surg Yr. Meds/Ff up Compliance Resolution
Hosp
Allergies
Immunization
Meds inc Herbal
Exp to Chem / Rad
Accidents / Trauma

For the the family history... The patient’s father is ___ y/o who is apparently alive and well. His mother died at the age of __ due to ...
He is ___th of # siblings, all the others are apparently well and healthy of the FHx is also remarkable for a paternal/ maternal history of ____. But there are no other history
of heredefamilial diseases like ____. The patient and his wife has ___ children who ___.

Delving deeper into the socioenviromental history…(SHEADSSS PeT)

Spouse- The wife/husband is ___ y/o, a ___ graduate, currently working as a ____. She is apparently healthy. She is a non -smoker and a non-alcoholic beverage drinker.
Relationship- The patient claims that they have good interpersonal relationship with each other, being able to share their issues and problems with each other, and dealing
with these altogether.

House - Type (concrete/wood, moldy, dust mites, surrounded by pine trees, along the road) Water source? Garbage?
E and O- Education and Occupation
Alc
Drugs
Diet
Smoke / SECOND-HAND smoke
Sex
Sleep
Pets
Travel hx

***DON’T FORGET OTHER DATA NEEDED FOR RISK STRATIFICATION, PROGNOSTICATION AND FINANCIAL
For the review of systems…
GENERAL: (-) fever, (+) fatigue, (-) body weakness (-) weight gain ie pregnant (-) weight loss (unintentional loss: >5% of your weight over 6 to 12 months )
INTEGUMENTARY: (-) lesions (-) discolorations (-) pruritus
HEAD: (-) headache (-) dizziness
Eyes: (-) diplopia, (+) blurring of vision, (-) flashes (-) floaters (-) dryness, (-) redness, (-) use of corrective lenses (-) eye pain
Ears: (-) vertigo, (+) difficulty hearing, (-) tinnitus, (-) pain, (-) discharge
NOSE: (-) colds, (-) epistaxis, (-) discharges (-) masses
MOUTH & THROAT: (-) mouth sores, (-) ulcers, (-) gum bleeding, (-) swelling, (-) dysphagia, (-) odynophagia (-) hoarseness
NECK: (-) masses (-) pain
RESPIRATORY: (-) cough (-) phlegm (-) hemoptysis (-) dyspnea
CARDIAC: (-) palpitations (-) chest pain (-) dyspnea (-) orthopnea (-) easy fatigabilty (-) edema
VASCULAR: (-) intermittent claudication, (-) leg cramps, (-) ulcers, (-) varicose veins
GIT: (-) nausea (-) vomiting, (+) abdominal/ hypogastric pain (-) diarrhea, (-)constipation, (-) melena, (-) hematochezia
URINARY: (+) dysuria (-) hematuria, (-) nocturia, (-) incontinence, (-) dribbling
GYNECOLOGICAL: (-) ulcerations, (-) itchiness, (-) dyspareunia, (-) history of OCP, (-) vaginal spotting/bleeding- 1 minimally-soaked regular-sized sanitary napkin
(-) foul smelling vaginal discharge (+) uterine contractions,
REPRODUCTIVE (Male): (-) Foul smelling penile discharge
MUSCULOSKELETAL: (-) stiffness, (-) joint pains, (+) lumbosacral pain (-)decreased mobility
HEMATOLOGIC: (-) bleeding tendencies
ENDOCRINE: (-) polyphagia, (-) polyuria, (-) heat/cold intolerance (-) profuse sweating (-) decreased appetite (-) hyperactivity (+) tophi
NERVOUS: (-) convulsions (-) tremors (-) fainting/ LOC
PSYCHIATRIC/EMOTIONAL: (-) substance abuse, (-) anxiety, (-) depression, (-) nervousness, (-) memory change, (-) insomnia (-)anorexia

1. Observe general state of health, Upon physical examination, the patient is

posture, motor activity, gait, - Healthy/weak-looking,
hygiene, body or breath odors, ectomorph,
facial expressions, affect, level of fully awake,
consciousness, manner of app dressed accdg to age, sex, and weather,
speaking, SIGNS OF DISTRESS well-groomed, good hygiene,
with good posture and normal gait,

conscious, coherent, oriented to time, place and person, in mild

discomfort, not in CPD
2. Assess level of consciousness,
coherence, orientation - Weak/ healthy-looking?
- Well-groomed, appropriately dressed for the weather
- Afebrile?
- Hooked to O2 inhalation at __lpm via nc, IV site insertion on
the left hand dorsum, hydrated with PNSS at a rate of ___
- Has a normal gait (appropriate for age),
- expresses appropriate emotions
- speaks in sentences,
- not in CP distress.

Explain to the patient the procedures to be done

II. VITAL SIGNS
SKILLS
BP : Position the patient in comfortable sitting position. Arms abducted, slightly flexed at the elbow and raised at BP app The vital signs include:
heart level. Deflate the cuff then center the bladder of the cuff over the brachial artery and wrapping the cuff around Pulse Ox BP of ___ --> elevated
the arm snugly fitting. Estimate the systolic pressure by palpation of the radial artery then rapidly inflate the cuff until
radial pulse disappears. Read this pressure then deflate cuff promptly and completely. Take the BP, using
Thermo CR = ___ --> tachycardic
auscultation. Place the bell of stethoscope over brachial artery. Inflate cuff until 30 mmHg above the palpated systolic RR =
pressure then deflate it slowly at a rate of 2-3 mm Hg per sec. Note systolic (Korotkoff 1) and diastolic pressure Weighing scale Temp =
(Korotkoff 5). WAIT 2 OR MORE MINUTES AND REPEAT. AVERAGE YOUR READINGS. IF THE FIRST TWO Ht scale SpO2 =
READINGS DIFFER BY MORE THAN 5 mmHg, TAKE ADDITIONAL READINGS. BP SHOULD BE TAKEN IN BOTH
ARMS AT LEAST ONCE. Take the radial pulse for 1 minute. Use pads of index finger and middle fingers, All within normal limits.
compressing the radial artery until maximal pulsation is detected.
12. Count respiratory rate in 1 minute by watching movement of the chest wall
3. Obtain height and weight, BMI, Weighing scale, tape measure Anthropometric measurements include:
WAIST CIRCUMFERENCE Ht= Wt= with a computed BMI = which
is classified as normal according to the asian pacific guidelines.

Pre-Preg Wt=
Wt gain =

III. SKIN
14. Assess skin moisture. Identify lesions (note location, distribution, arrangement, The skin is fair, no jaundice, no pallor, no cyanosis with noted
type and color), SKIN COLOR, SCARS, PLAQUES, NEVI, TURGOR lesions described as ____ (hyperpigmented/ erythematous,
maculopapular rash on the UE) localized at ___. There are no
evident scars noted.

It is dry and warm to touch with good skin turgor.

15. Inspect and palpate hair and nails. The hair is black, with fine texture, and even distribution with
16. Study hands and feet no signs of infestation.

The scalp is dry with no scaling.

The nailbeds are pinkish, with no signs of pitting or

clubbing.
Capillary refill time is <2s.

IV. EXAMINATION OF THE HEAD, EYES, EARS, NOSE, THROAT, NECK

HEAD: Examine the hair, scalp, skull and face Ant: Bregma The head is atraumatic, with no gross deformities nor
where the __ tenderness.
sutures meet
Post: Lamda Pedia: non sunken fontanelle

EARS: Inspect the external ear or auricle. The ears are normally set, with no tragal tenderness bilaterally.
20. Inspect auditory canal with otoscope, selecting the largest available speculum. Otoscope Through the otoscope there was minimal cerumen,
Position patient’s head to allow best insertion of the otoscope. Pull the auricle gently the tympanic membranes were pearly white, with visible cones of
upwards and backwards to straighten the canal. Hold otoscope between thumb and light seen, and with no perforation nor bleeding .
fingers. Insert the speculum gently into the ear canal and do inspection of the
auditory canal, cone of light, tympanic membrane ***AC > BC, no lateralization.
25. Assess hearing (auditory acuity – CN VIII): Ask the patient to occlude one ear
with a finger and then examiner whispers softly or rubs fingers 1 to 2 feet away
towards the un-occluded ear.
IF ACUITY IS DIMINISHED, check air and bone conduction: Tuning fork
Weber test (CN VIII): Test for lateralization
Place the lightly vibrating tuning fork firmly on top of the patient’s head. Ask where
the patient hears it. Rinne test (CN VIII): Compare air conduction and bone
conduction
Place the base of a lightly vibrating tuning fork on the mastoid bone. When the
patient can no longer hear the sound, quickly place the fork close to the ear canal
and ask whether sound can still be heard.
EYES (Close 1 eye)
30. Check visual acuity using a Snellen eye chart (CN II). Position the patient 20 Snellen Chart / The eyes are equally aligned with and equidistant to each other,
feet from the chart. Ask patient to cover one eye with a card and read the smallest Jager’s non-sunken eyeballs, w/ anicteric sclerae, pink palpebral
line of print. Repeat procedure on the other eye conjuntiva, no excessive eye discharge.
No ptosis noted.

33. Assess visual fields (CN II). Ask the patient to look with both eyes into your (good visual tracking/visual field)
eyes. While you return the patient’s gaze, place your hands about 2 feet apart,
lateral to the patient’s ear. Instruct the patient to point to your fingers as soon as
they are seen. Slowly move your wiggling fingers of both your hands along the
imaginary bowl and toward the line of gaze until the patient identifies them. Repeat
this pattern in the upper and lower temporal quadrants.
36. Inspect external eyes: Stand in front of the patient and survey eyes for position
and alignment.
39. Inspect the eyebrows and eyelids
40. Inspect the region of the puncta, conjunctiva and sclera.
41. Ask the patient to look up as you depress both lower lids with your thumb .
42. Press the closed eyes.
41. Inspect the cornea and lens, using a penlight shined obliquely across the eye Penlight
42. Inspect iris, pupils for size and shape and symmetry (CN III, IV, VI)
43.Assess pupillary reflexes (CN III, IV, VI). Ask the patient to look into the
distance and shine a bright light obliquely into each pupil in turn
44. Assess Extraocular movements (CN III, IV, VI): From 2 feet directly in front of
the patient, shine a light into the patient’s eye and ask the patient to look at it.
Inspect the reflection in the corneas. Ask the patient to follow your finger or pencil
as you sweep through the six cardinal directions of gaze
46.Ophthalmoscopic Exam (CN II): Turn the lens disc to the 0 diopter. Hold Ophthalmoscope
ophthalmoscope in your right hand to examine the patient’s right eye, and hold it in
the left hand to examine the left eye. Instruct the patient to look slightly up and over
your shoulder. Place yourself about 15 inches away from the patient. Shine light on
pupil and look for red-orange reflex. Then examine optic disc, retinal vessels, retina
and macula.
NOSE AND PARANASAL SINUSES
50. Inspect the anterior and inferior surfaces of the nose. Push gently on the tip of The nasal septum is at the midline, no alar flaring, nasal
the nose to widen the nostrils. turbinates are not congested, with minimal mucous threads
noted, no bleeding, and no tenderness.
51.Inspect the inside of the nose using an otoscope with the largest available Nasal speculum
speculum. Tilt the patient’s head back slightly and insert the speculum
52. Inspect the nasal septum, inferior and middle turbinates
53. Palpate the frontal and maxillary sinuses There are no frontal nor maxillary sinus tenderness.
MOUTH AND PHARYNX
55. Inspect the lips The lips are pinkish and dry, no circumoral cyanosis,
56. Inspect oral mucosa using good light and tongue blade with moist tongue and buccal mucosa,
57. Inspect gums, teeth, hard palate with good dentition,
uvula is at the midline,
with non-congested tonsillopharyngeal wall.
58. Inspect the tongue and floor of the mouth. Ask patient to put out his tongue then Penlight
to move it side to side (CN XII) Tongue
depressor
59. Ask the patient to put his tongue on the roof of the mouth.
60. Inspect the pharynx. Tongue in normal position. Ask the patient to say “ah” and
inspect soft palate, tonsils and pharynx. May use tongue blade. Check position and
symmetry of palate and uvula at rest and with phonation (“aah”) (CN IX, X). “kaka
lala”

NECK 2 Rulers
61. Palpate the lymph nodes in the following sequence: Preauricular ; posterior The neck has no gross deformities,
auricular; occipital; tonsillar; submandibular; submental; superficial cervical; deep trachea is at the midline,
cervical chain; supraclavicular no supraclavicular retractions,
62. Inspect trachea and feel for any deviation by placing your finger along one side no CLAD.
of the trachea and note the space between it and sternomastoid. Compare with the
other side. The thyroid gland is not enlarged, which rises normally upon
63. Inspect the thyroid gland. Tip the patient’s head back a bit and inspect the degluttion, non tender.
region below the cricoid cartilage. Palpate the thyroid gland; Flex the neck slightly
forward. Place the fingers of both hands on the patient’s neck with index finger just Additionally!!!
below the cricoids cartilage. Ask patient to swallow 1. there is no neck vein engorgement,
2. JVP (in rel to the sternal angle) is measured to be 7-8 cmH2O
3. and no carotid bruits heard.
Inspect and palpate the carotid pulsations. Listen for carotid bruits using bell of
stethoscope.

V. EXAMINATION OF THORAX AND LUNGS

Posterior Thorax
66. The patient should be sitting with the posterior thorax exposed. The doctor The back has no gross deformities,
assumes a midline position behind the patient. Inspect the cervical, thoracic and no gross vertebral deviation nor tenderness.
upper lumbar spine (you will check for ROM of the thoracic and lumbar spine
towards the end of the complete physical when the patient is standing up). Palpate
the spinous processes of each vertebra for tenderness with your thumb or by
thumping with the ulnar surface of your fist
Inspect the shape and movement of the chest wall. Lung findings reveal
Place your thumbs at the level of the 10 th ribs with your fingers loosely grasping the (I) SCWE, (-) lagging (-) intercostal retractions
rib cage and gently slide them medially. Ask the patient to inhale deeply and
observe whether your thumbs move apart symmetrically
Palpate for tactile fremitus (Pa) …normal tactile fremitus,
72. Use either the ball of your palm or the ulnar surface of your hand for palpation.
Ask the patient to repeat the words “ninety-nine. You may palpate one side at a time
or use both hands simultaneously to compare sides. Palpate in four locations on
both sides of the chest and compare (Bates p. 308)
75. Ask the patient to keep both arms crossed in front of the chest. Press the DIP (Pe) Posterior peripheral lung fields are resonant,
joint of the left middle finger firmly against the chest wall, avoiding contact with other
fingers. Strike this DIP joint with the tip of the right middle finger, swinging from the
wrist. Percuss in seven areas on each side (Bates p 310)
78. Auscultate for breath sounds. Instruct the patient to breathe deeply through an (A) With clear breath sounds, normal vocal fremitus, no
open mouth. Listen with the diaphragm of the stethoscope in the same seven areas egophonopy, whisper pectoriloquy nor bronchophony noted.
in which you percussed. (appreciable),
Assess for costovertebral tenderness * No CVA tenderness.
109. Place the ball of one hand in the costovertebral angle and strike it with the
ulnar surface of your fist
Anterior Thorax
80. The patient may be either sitting or supine. The drape should be adjusted to
allow exposure of the area being examined.
81. Inspect the shape of the patient’s chest and movement of the chest wall Tape measure ***( 1st) The patient appears to have normal chest size
barrel chest / Pectus excavatum / Pectus carinatum.

82. Palpate for tactile fremitus There are the same lung findings on the anterior chest at that
Use the ball of the palm or ulnar surface of the hand to palpate in 3 areas on each of the posterior.
side of the anterior chest (Bates p 316)
83. Percuss the anterior and lateral chest, comparing sides, in 6 areas on each side
(Bates p 317).
84. Auscultate the anterior chest, comparing sides in the 6 areas on each side
where you percussed

VI. EXAMINATION OF THE CARDIOVASCULAR SYSTEM

85.The patient should be supine with the upper body raised by elevated the table to Drape Heart findings reveal adynamic precordium,
about 30°. The drape should be arranged to expose the precordium. The
examiner should stand at the patient’s right side
86. Observe the jugular venous pulsations and measure jugular venous pressure in 2 rulers
relation to the sternal angle.

89. Inspect the precordium: look for apical impulselook for any other movements PMI at the 5th ICS LMCL,
Palpate for precordium no heaves, no thrills,
Use the palmar surfaces of several fingers to locate the PMI—can switch to one normal rate, regular rhythm,
fingertip when located
i) Displace a woman’s breast upward or laterally, or ask her to do
this for you
ii) Note location of PMI, amplitude and duration
90. Palpate for the RV impulse along the lower left sternal border
91. Auscultation of the heart …S1 heard louder than S2 at the apex and S2 louder than S1
Listen to the heart with the diaphragm of your stethoscope in the R 2 nd ICS, L 2nd at the base,, no extra heart sounds like murmurs noted.
ICS, L 3rd or 4th ICS, and the lower left sternal border (5 th ICS) and at the apex (may
also start at the apex and proceed to the base)
92. Listen to the heart with the bell of your stethoscope in the same five listening
areas
The breasts are symmetrical, with no deformities, dimpling or
EXAMINATION OF THE BREASTS peau d’ orange, no palpable masses, no tenderness. There
are no discharges. No axillary LN.

VII. EXAMINATION OF THE ABDOMEN

Skills Ruler
93. The patient should be in a supine position with arms at side or folded across the
chest. The drapes should be arranged to expose the abdomen from above the
xyphoid process to the symphysis pubis. Approach the patient from his right side,
then bend the knees!
96. Inspect the abdomen
97. Auscultate the abdomen as the next step in the exam after inspection The abdomen is
a) Place the diaphragm of the stethoscope gently on the abdomen flabby/ globular/ gravid, with no striae nor scars, distended
b) Listen for bowel sound. Listening in one spot is sufficient with abdominal girth of __ cm,
c) Listen for an aortic bruit on the midline just above the navel with normoactive bowel sounds, no bruits appreciated,
no tenderness upon light and deep palpation, no palpable
masses, and no hepatojugular reflux.

If pregnant:
FHt Estimated FWt
LM1-4
FHTone
>Uterus was well-contracted, palpated 1-2 fingerbreadths
below the umbilicus

98. Percuss the abdomen lightly in four quadrants

99. Percuss for liver dullness Liver span is 6-15cm along the RMCL.
d) Define the lower edge of liver dullness in the mid-clavicular line, starting
at a level below the umbilicus
100. Define the upper edge of liver dullness in MCL, starting in the area of lung
resonance (Gently displace a woman’s breast as necessary)
101.Measure in cm with a ruler the vertical span of liver dullness in the MCL
102.Percuss for splenic dullness No hepatosplenomegaly.
Percuss along the L lower chest wall between the lung resonance above and the
costal margin moving laterally. Ask the patient to take a deep breath and percuss
again in this area
103. Palpate the abdomen lightly in four quadrants and in the suprapubic and
epigastric areas. Use a gentle, light dipping motion, then firm.
105.Palpate for the liver edge
a. Place your R hand on the right abdomen lateral to the rectus muscle,
beginning more than 3 fingerbreadths below the costal margin
b. Ask the patient to take in a deep breath
Palpate upwards trying to feel the descending liver edge, using a rocking motion.
May also use the “hooking technique”
107.Palpate for a spleen tip
a. Reach over and around the patient with your left hand to support and press
forward the lower left rib cage. Press inward towards the spleen with your right
hand, beginning at least 3 finger breadths below the L costal margin. Ask the
patient to take in deep breaths, trying to feel the spleen tip as it comes down to meet
your fingertips

VIII. EXAMINATION OF THE LOWER EXTREMITIES

Peripheral Vascular System: Ext: No gross deformities on the UE and LE,
110. With the patient supine: Palpate the femoral pulses and, if indicated, the popliteal pulses. no varicose veins, no edema, with normal equal
Palpate the inguinal lymph nodes. Inspect for lower extremity edema, discoloration or ulcers. peripheral pulses of (+2).
Palpate for pitting edema.
111. With the patient standing: Inspect for varicose veins
112. Musculoskeletal System: Note any deformities or enlarged joints. If indicated, palpate the There’s no limitation of ROM on the elbows, hip,
joints, check their range of motion knees and ankles,

Or with difficulty of dorsiflexion and abduction, no

crepitations noted.

113. Motor examination: Assess extremity strength. Repeat on upper extremities. There’s normal muscular strength of +5,

114. Sensory exam: Ask whether patient can feel light touch and temperature of a cool object in Sensory of 100% and
each distal extremity; check double simultaneous stimulation using light touch on hands
115. Check biceps and patellar reflexes Normal reflexes of +2 on all extremities
*SLRT/ Lassegue’s Test, Pyriformis test, Anterior Drawer
 CN 1, 5, 7, 11 --> UR --> Cerebellum + Gait
Assess sense of smell (CN I): Ask patient to identify odorant (e.g. toothpaste, coffee) with eyes
closed
Facial sensation to light touch and temperature (CN V); Cotton
OPTIONAL: corneal reflex, jaw clench (motor component) Neuro hammer
Check facial symmetry (CN VII): Test eyebrow elevation, forehead wrinkling, eye closure,
smiling, cheek puff
Ask patient to shrug shoulders and rotate head to each side against resistance (CN XI)
*Spurling/Lemettire/TOS
MSR of upper extremities.
Check coordination and cerebellar functions: Rapid alternating movements of the hands; finger-
to-nose and heel-knee-shin maneuvers
Check gait. Observe patient while walking normally, on the heels and toes, and along straight
line
GENITALIA Gloves and KY Genitalia:
Speculum Grossly female, pubic hair in an inverted triangle
distribution, (-) watery discharge, (-) scar
Or grossly male, pubic hair in a diamond distribution,
IE (-) abnormal penile discharge (-) tender
IE: Introitus admits 2 fingers with ease, smooth
vaginal wall, cervix midline, soft, 10 cm dilated, 100%
effaced, cephalic, station +3, (-) BOW, (-) blood on
examining finger
DRE Gloves and KY DRE: There are no external hemorroids noted, no
fistula, no discharges, with good sphincteric tone, no
palpable masses, no tenderness, with brownish fecal
material on the tactating finger, non-bloody
Neurologic findings:
The patient has a GCS of 15.
(Cerebrum) Fully awake, comfortably sitting/lying on chair/bed,
conversant.
(Cerebellum) Unremarkable cerebellar signs like nystagmus, tremors,
(-) dysdiadochokinesia/ finger-to-nose test, (-) lifts (-) dysmetria
(-)rebound phenomenan (reflex when a limb is moved against resistance)
nor gait problems

CN I : The patient was able to diff the smell of coffee vs mint.

CN II: Both pupils are dilated upto 3mm equally reactive to light and
accommodation. Normal visual fields. ROR is seen in both eyes.
CN III, IV, VI: EOMs are intact.
CN V: Pt has intact corneal reflex and is able to clench teeth ( use
masticatory muscles )
CN VII: She/He is able to puff cheeks, close eyelids, raise eyebrows,
CN VIII: She/He is able to hear, with AC > BC bilaterally.
CN IX, X: Able to say “ahh” and w/ intact gag reflex
CN XI: She/He is able to raise shoulders bilaterally, against resistance.
CN XII: The tongue and uvula are not deviated.

Pathologic reflexes:

(-) Babinski
(-) Brudzinski sign
(-) Kernig’s sign

SALIENT FEATURES
S&O (State in a story type…Again we are presented with a case of a 54y/o, male, a known ____ who has a 3 days history of ___,with associated symptoms of ___.)
From these data, we can deduce that he patient has # problems. As far as the most active and important problem is concerned, we focus on the first one:
_____________ ---> which can be taken under 1 diagnosis: My assessment: _____

ASSESSEMENT:
Going back to the CC of our pt which is ___, together with ____. These serve as CLINICAL CLUES in coming up with such assessment.

BASIS:
Of note are the subjective findings of our patient… and according to these strongly support the diagnosis of a ______.
1st subjectively, there’s the presence of:
2nd objectively, there’s the presence of:
According to ____, s/sx coincides, hence we can reconcile such diagnosis as a probable cause with those that are going on with our patient.
According to (CPG/Journal)

Of note are the

1. S/sx
2. Predisposing Factors
3. Comorbidities of the patient which increases the risk…

REMEMBER TO ALWAYS CORRELATE. GO BACK TO THE PATIENT!

(May be in a CPC type…)
The manner by which (Dse) ____ could affect our body, could easily be understoon by relating the ____ system with ___.
Imagine our body to be Baguio City where

DDX:
We should however not settle for 1 diagnosis alone, and make sure to include perhaps a more serious diagnoses. Anatomically, as far as the cc of the pt is
concerned or in relation to the cc of the pt…

MANAGEMENT:
GENERAL:
Admit / Treat as OPD.
Monitor I and O.
CBR w/ BRPs
Diet (low salt (<6g/day), low fat, low sugar)
SPECIFIC:
DIAGNOSTIC (Gold std, Mainstay, Sp/Sn)
THERAPEUTIC (GN/BN, Class and Ind, MOA, S/E)
SUPPORTIVE
MVS q. WOF
PATIENT EDUCATION
Good understanding / knowledge of the dse.
Medication compliance.
Lifestyle modification.

*Family - It is also important to involve the FAMILY in the management of the pt, not only does it affect the dynamics of the family but also the recovery of
the patient as well.
*Commnity - Ideally
Refer to
Follow-up

Omnium rerum principia parva sunt.

The beginnings of all things are small.

Vita non est vivere, sed valera vita est.

Life is not about living, but to live a good life.